Aims We present a series of pre-auricular sinus infections managed at Royal Children’s Hospital, Melbourne. We compare the rates of recurrence and wound dehiscence after a “hot” excision of an actively infected sinus versus after elective second stage excision. We also examine the microbiology to guide anti-microbial prescribing in an Australian setting. Methodology A retrospective review of pre-auricular sinuses excised over a 10-year history between 2014 and 2024. Results Seventy-five sinuses were treated with excision (age 3 months – 16 years). 70.7% of sinuses had been previously infected with the majority treated with incision and drainage. Elective excision occurred in 85.3% of cases, while the remaining 14.7% underwent excision at the time of active emergency infection. In the elective excision group, 33.3% of sinuses were actually infected at time of excision. There were two cases of sinus recurrence (2.7%) in the elective group. There was no significant difference in recurrence rates with regards to previous infections, previous management of infections, active infection at the time of excision nor elective versus emergency excision. No wound complications in those who underwent hot excision. The most common microorganisms were staphylococcus aureus (31%), anaerobes (20.7%) and upper respiratory tract flora (17.2%). Multiple organisms were implicated in 48.3% of cases. The commonly prescribed antibiotics were cephalosporins or penicillins, in particular flucloxacillin or amoxicillin-clavulanate. Conclusion Traditionally, the treatment paradigm of infected preauricular sinuses has been to settle the infection with antibiotics and drainage of abscess followed by delayed second-stage excision. This study demonstrates that emergency excision of actively infected sinuses does not lead to increased recurrence rates or wound complications. We also suggest the addition of anti-anaerobic antimicrobials in the treatment of infection.